EyeWorld Asia-Pacific March 2016 Issue

March 2016 Glaucoma treatment 30 EWAP SECONDARY FEATURE ophthalmologist and a patient at all stages in the treatment paradigm are far wider today than ever before. With appropriate thoughtful management, successful long-term outcomes are much more likely. On ‘Non-adherence in glaucoma therapy’ In the management of all chronic conditions, non-adherence and non-persistence pose major challenges that threaten long-term patient outcomes. Glaucoma is a classic example of such a clinical situation: the disease itself presents only subtle symptoms until damage is moderately severe or worse, the treatment itself is inconvenient, non-intuitive and intrusive on a person’s lifestyle and quality of life, and, finally, there are no immediate dire consequences if the treatment program isn’t followed. From the extensive adherence/ persistence literature, we understand about 25% of our glaucoma patients are carefully adherent, about 25% spectacularly non-adherent, and about 50% part- time adherent across a spectrum from fairly regular with their medications through to mostly irregular, including so-called “drug holidays”. It is this 50% of patients in the middle of the adherence spectrum who we can influence to improve drug delivery regularly by education (understanding the two simple facts that glaucoma can blind them and that treatment can protect their vision) and by support, including regular reminders. While all patients deserve such information and support, some are more in need of it than others. How do we identify the most-at- risk non-adherent patients? An open non-judgemental therapeutic alliance between ophthalmologist and patient is a critical foundation. Patients generally do not volunteer non-adherence, partly because they are in denial, partly because it might be unintentional, partly because they don’t wish to “disappoint” us and partly because, quite reasonably, they ask “how can you expect me to remember what I have forgotten to do?” Patients with neck, shoulder, hand and/or finger weakness, tremor, and arthritis are more likely to encounter physical barriers to drop instillation. Unless they can be guided to overcome these, or have a relative or carer instil the drops, eye medications might not be suitable for them. Patients who fail to attend appointments are more likely not to be using their drops. Unexpected eye pressure increases at a consultation or disease progression with apparently controlled pressures at visits could both suggest non-adherence before or between visits. Lack of expected side effects (eye lash growth or conjunctival injection with prostaglandin analogues, for e.g.) could be another hint that the drops are not being used regularly. Importantly, if adherence cannot be assured, other pressure- lowering strategies (SLT or even surgery) might need to be considered. Shamira Perera, MD On ‘Extending the duration of glaucoma medications’ We are very fortunate in Singapore to have been involved first hand with all the modalities mentioned. Intrigued to do some advanced market research, we conducted a questionnaire-based study to evaluate the factors patients consider in their choice of a sustained-release implant. It seemed as though patients accurately understood the tradeoffs between efficacy and risk in their decision making. While two thirds were open to the sustained release concept, be it in an intracameral, subconjunctival or punctal location, 20% objected to any injections whatsoever. 1 A delivery duration of about 6 months would fit neatly with the timing of clinic visits but the difficulty lies with reproducible pharmokinetics. Preliminary data suggests the intracameral agents reduce the unwanted periocular side effects of prostaglandin analogues, too, as they do not leak out of the eye, and this may prove to be the winning asset. The downside though, is that Asian eyes with their narrower angles may be considered ineligible and that might provide the push towards the alternatives. On ‘Navigating through the Sea of Glaucoma Medications’ Introducing a fixed-dose combination medication as secondline (as Dr. Wallace advocates) may represent a rapid acceleration to maximal tolerable medical therapy. While advantageous for some rapidly progressing patients, this must be balanced against costs and side effects. Certainly in Singapore, the usage of fixed combinations is not so common. Opinions on generic medications vary hugely around the Asia-Pacific region but everyone agrees these have certainly shaken up the market. Previously used as a last stop before surgery, SLT has been gradually brought forward in its usage, to firstline treatment for younger, busier patients similar to Dr. Parekh’s use. We are collaborating in a multicenter randomized controlled study comparing SLT and prostaglandin analogues as firstline therapy, concentrating on the quality of life and cost effectiveness aspects. 2 On ‘Non-adherence in glaucoma therapy’ We found compliance certainly seems worse among Asians. 3 I feel a simple but thorough explanation at the first visit by the doctor will help patients understand their role in their treatment. My suspicion is How doctors - from page 28